Hypertensive crisis clinic emergency care. Emergency care hypertensive crisis Hypertensive crises etiology clinic emergency care

Hypertensive crisis- an urgent serious condition caused by an excessive increase in blood pressure, manifested clinically and involving an immediate decrease in the level blood pressure to prevent or limit target organ damage.

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Epidemiology

This pathological condition is one of the most common reasons for calling an ambulance. medical care.

In Western European countries, there is a decrease in the incidence of hypertensive crises in patients with arterial hypertension - from 7% to 1% (as of 2004). This is due to improved therapy arterial hypertension and an increase in the frequency of timely diagnosis of the disease.

In Russia, the situation remained at an unsatisfactory level: according to data for 2000, only 58% of sick women and 37.1% of men knew about the presence of the disease, despite the fact that the prevalence of the disease among the population was 39.2% in men, 41 in women, one%. received drug treatment only 45.7% of women and 21.6% of men.

Thus, only about 20% of patients with arterial hypertension received medical treatment of varying degrees of adequacy. In this regard, the absolute number of hypertensive crises naturally increases.

In Moscow, from 1997 to 2002, the number of hypertensive crises increased by 9%. Also, a significant role in the increase in the frequency of occurrence of hypertensive crises is the lack of proper continuity of treatment between emergency medical care, a therapeutic hospital and a polyclinic.

Classification

In Russia, there is currently no single generally accepted classification of hypertensive crises. In the USA, Canada, the concept of "hypertensive crisis" does not exist. There is a definition of "critical arterial hypertension", that is, in essence, a complicated hypertensive crisis (uncomplicated hypertensive crisis is not considered there, since it is characterized by low mortality). In the world, in most guidelines, clinical classification based on the severity of clinical symptoms and presence of complications. Based on this classification, there are:

  • Complicated hypertensive crisis- emergency condition, accompanied by damage to target organs; can be fatal, require immediate medical attention and urgent hospitalization in a hospital.
  • Uncomplicated hypertensive crisis- a condition in which there is a significant increase in blood pressure with relatively intact target organs. Requires medical attention within 24 hours of onset; hospitalization is usually not required.

Pathogenesis

In the development of a hypertensive crisis, an important role is played by the ratio of the total peripheral vascular resistance to the value of cardiac output. As a result of violations of vascular regulation, spasm of arterioles occurs, resulting in an increase in heart rate, a vicious circle develops and a sharp rise in blood pressure occurs, and due to spasm, many organs are in a state of hypoxia, which can lead to the development of ischemic complications.

It has been proven that during a hypertensive crisis, hyperactivity of the renin-angiotensin system is observed, which leads to a vicious circle that includes vascular damage, an increase in ischemia and, as a result, an increase in renin production. It was found that a decrease in the content of vasodilators in the blood leads to an increase in the total peripheral vascular resistance. As a result, fibrinoid necrosis of arterioles develops and vascular permeability increases. The presence and severity of the pathology of the blood coagulation system is extremely important in determining the prognosis and associated complications.

Clinic and diagnostics

During a hypertensive crisis, symptoms of impaired blood supply to organs and systems, most often the brain and heart, are observed:

  • An increase in systolic blood pressure above 140 mm Hg. - above 200 mm Hg. [ ]
  • Headache.
  • Dyspnea.
  • Pain in the chest.
  • Neurological disorders: vomiting, convulsions, impaired consciousness, in some cases clouding of consciousness, strokes and paralysis.

A hypertensive crisis can be fatal.

A hypertensive crisis can be especially dangerous for patients with pre-existing diseases of the heart and brain.

Treatment

For the relief of a complicated hypertensive crisis, use intravenous administration such medicines like nifedipine, clonidine. During the first 2 hours, the level of mean blood pressure should be reduced by 20-25% (no more), food should not be eaten, then, over the next 6 hours, blood pressure should decrease to 160/100 mm Hg. Art. Further (with improvement in well-being) they are transferred to tablet preparations. Treatment starts at prehospital stage. Compulsory hospitalization in the intensive care unit.

Depending on concomitant diseases, the therapy of a hypertensive crisis may differ. Complications of a hypertensive crisis: pulmonary edema, cerebral edema, acute violation cerebral circulation.

Eufillin 2.4% 5-10 ml intravenously, bolus in 3-5 minutes Lasix (furosemide) 1% 2-4 ml Captopril 6.25 mg, then 25 mg every 30-60 minutes orally until blood pressure decreases (if no vomiting)

With convulsive syndrome: Relanium (seduxen) 0.5% 2 ml intravenously, by stream, slowly Magnesium sulfate 25% 10 ml can be administered intravenously, by stream in 5-10 minutes With left ventricular failure: Sodium nitroprusside 50 mg intravenously, drip

Forecast

The prognosis in the case of a complicated crisis is unfavorable. 1% of patients suffering from chronic arterial hypertension suffer from hypertensive crises. Once developed, a crisis tends to relapse.

In the 1950s (in the absence of antihypertensive drugs), life expectancy after the development of a crisis was 2 years.

Survival, in the absence of adequate therapy, over 2 years was 1%. Mortality within 90 days after discharge from the hospital among patients with hypertensive crisis is 8%. 40% of patients within 90 days after discharge from the hospital due to a hypertensive crisis are again admitted to the intensive care unit. If uncontrolled arterial hypertension is accompanied by 2% mortality in 4 years, then in patients against the background of uncontrolled arterial hypertension with crises, 17% mortality is accompanied by 4 years. [ ]

This condition is dangerous for the development of very serious complications, such as stroke, pulmonary edema, acute heart failure. Therefore, it is important to provide assistance as soon as possible.

Classification of hypertensive crises

  • uncomplicated;
  • complicated.

In the first case, there are no serious violations of the function of the heart, brain and kidneys. After taking the medication, the pressure level normalizes within a few hours.

A complicated crisis occurs much less frequently, it is characterized by damage to target organs. It can be:

  • encephalopathy (impaired brain function) with loss of memory or consciousness;
  • stroke;
  • subarachnoid hemorrhage;
  • acute coronary syndrome;
  • pulmonary edema;
  • dissecting aortic aneurysm.

There are several other conditions in which an increase in blood pressure to high numbers is considered dangerous:

  • taking drugs, such as cocaine or amphetamines
  • brain injury
  • preeclampsia or eclampsia during pregnancy.

Causes

  • untreated arterial hypertension;
  • improper use of drugs for hypertension;
  • diseases thyroid gland, kidneys, adrenal glands;
  • heart diseases;
  • preeclampsia in pregnant women;
  • taking cocaine or amphetamines;
  • head injury;
  • severe burns;
  • abuse of nicotine/alcohol;
  • stress.

Signs and symptoms of a hypertensive crisis

An uncomplicated crisis can manifest itself only as an increase in pressure. In more severe cases, there are:

  • headache;
  • drowsiness;
  • visual impairment;
  • confusion;
  • nausea, nausea;
  • increasing pain in the chest;
  • increasing shortness of breath;
  • puffiness.

Diagnostics

During the examination, the doctor will ask a few questions to provide adequate assistance. You will need to tell about all the medications you take, as well as nutritional supplements or herbal preparations. There is no need to hide the use of drugs, if any. The doctor also learns about the medical history - the condition first arose or it repeats.

In addition to a one-time pressure measurement, the following diagnostic methods are used:

  • daily monitoring of blood pressure;
  • examination of the fundus for the detection of edema and hemorrhages;
  • clinical blood and urine tests;
  • computed tomography (CT) to rule out stroke.

Treatment of a hypertensive crisis

The goal is a smooth decrease in blood pressure. In general, the rate of pressure decrease should not be more than 25% in the first 2 hours. Then, no more than a day before, it is recommended to return the pressure level to the initial level.

Help with uncomplicated hypertensive crisis

Treatment can be done at home. Drugs are prescribed mainly in tablets, less often - in injections. expedient dosage forms with a fast onset of effect and a short withdrawal period:

  • captopril 25 mg;
  • nifedipine 10 mg;
  • moxonidine 0.2-0.4 mg;
  • propranolol 10-40 mg.

The tablet must be sucked or placed under the tongue. All of these drugs have contraindications and side effects to be discussed with your doctor. If the crisis arose for the first time or is difficult to treat, often recurs, then lowering blood pressure and further selection of drugs is carried out in a hospital.

Help with complicated hypertensive crisis

If there are symptoms of damage to the brain, heart or kidneys, then it is necessary to urgently call ambulance. Treatment in this case is carried out either in emergency cardiology, or in intensive care of the cardiology or therapeutic department. If a stroke is suspected, the patient is taken to the neuro-reanimation or intensive care unit of the neurological department. The main symptoms of a stroke:

  • inability to move or severe weakness in the muscles on one side of the body;
  • difficulty in moving the tongue, lips, sagging half of the face;
  • inability to speak clearly.

With a stroke, a rapid and significant decrease in pressure can aggravate the situation, so the drugs are carefully dosed. With a dissecting aortic aneurysm or acute left ventricular failure, on the contrary, the pressure must be reduced quickly: within the first 10 minutes - by 25% of what was registered.

When providing assistance, drugs are administered intravenously. It can be:

  • enalaprilat 1.25 mg in 1 ml;
  • nitroglycerin concentrate for infusions 1 mg in 1 ml;
  • sodium nitroprusside 30 mg in 5 ml and 50 mg in 2 ml;
  • metoprolol solution 1 mg in 1 ml;
  • furosemide in ampoules of 20 mg in 2 ml;
  • pentamine 50 mg in 1 ml.

The choice of a specific drug, dose and method of administration is made only by a doctor. So, with damage to the heart with the development of acute coronary syndrome, nitroglycerin is appropriate. In acute encephalopathy caused by an increase in blood pressure - sodium nitroprusside, with pheochromocytoma - phentolamine, and in acute left ventricular failure - enalaprilat and furosemide.

Prevention of hypertensive crisis

  • Maximum control chronic diseases - diabetes, diseases of the thyroid gland and adrenal glands.
  • Measurement of blood pressure twice a day, in the morning and in the evening in a sitting position. The recommendation applies to those people who already have hypertension. It is advisable to enter the results in a diary of observations and then show it to the attending physician.
  • Eating more fruits, vegetables, whole grain breads, legumes, lean fish and meats, and dairy products. Limit salt and hydrogenated fats. On the recommendation of a doctor, you need to eat more foods containing potassium and magnesium.
  • Weight control. Even a small loss in obesity can normalize blood pressure.
  • Develop a physical activity plan with your doctor.
  • Limiting alcohol consumption to 1 serving per day for women and two for men. 1 serving is approximately 150 ml of wine, 350 ml of beer or 45 ml of liquor.
  • Smoking cessation.

Sources

  1. Hypertensive Crisis: When You Should Call 9-1-1 for High Blood Pressure, updated 30 November 2017, http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/Hypertensive-Crisis UCM 301782_Article.jsp#.WVonE4jyjIU
  2. High blood pressure (hypertension), Overview, Mayo Clinic, http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/definition/con-20019580?p=1
  3. Clinical guidelines for diagnosis and treatment arterial hypertension(Developed by experts of the Russian Medical Society for Arterial Hypertension. Approved at the meeting of the plenum of the Russian Medical Society for Arterial Hypertension on November 28, 2013 and the specialized commission on cardiology on November 29, 2013) https://www.cardioweb.ru/files/Klinicheskie recommendations/diagnostics i treatment arterialnoj_gipertonii.docx
  4. High Blood Pressure and Hypertensive Crisis, Reviewed by James Beckerman, MD, FACC on October 10, 2017, WebMd

A hypertensive crisis is a sudden increase in blood pressure, accompanied by complaints and pathological changes on the part of the brain and the cardiovascular system against the background of autonomic disorders.

A hypertensive crisis can develop with any degree of arterial hypertension or with symptomatic arterial hypertension. Sometimes a hypertensive crisis can occur in a healthy person. A crisis state is usually provoked by:

Psycho-emotional overload

change of weather

Abuse of coffee, alcoholic beverages

hormonal disorders

Cancellation of previously taken antihypertensive drugs

diseases of the brain (stroke), heart (myocardial infarction, angina pectoris attack), kidneys.

Signs of a hypertensive crisis:

sudden onset within minutes or 1-3 hours

The blood pressure level is individually high (in one patient it is 240/120, in another it is 130/90). It depends on the initial blood pressure level. If the patient has a constantly low level of pressure, even a slight increase can cause a hypertensive crisis.

the presence of complaints from the heart (pain in the heart, palpitations)

The presence of complaints from the brain (headaches, dizziness, various visual impairments)

The presence of complaints from the vegetative nervous system(chills, trembling, sweating, a feeling of a rush of blood to the head, a feeling of lack of air, etc.).

Hypertensive crises are divided into:

Hypertensive crisis with a predominance of neurovegetative syndrome. Usually such a crisis begins quickly, occurs after stress, psycho-emotional stress. The patient complains of a throbbing headache, dizziness, nausea, and rarely vomiting. This condition is accompanied by a feeling of fear and a feeling of lack of air. The patient may be agitated, trembling in the hands, chills, sweating. This state lasts for a short time from 1 to 5 hours. Often after a crisis there is profuse urination. Usually such a crisis does not pose a threat to life.

water-salt hypertensive crisis. It is caused by the renin-angiotensin-aldosterone system. This is the system that normally maintains the constancy of the internal environment of the human body, in this case, blood pressure. There are complaints of severe headache, constant nature, nausea and vomiting. Patients are often lethargic, sometimes they are disoriented in space and time. They can forget what day it is, get lost in a familiar area. Various visual impairments are possible - double vision, "flies" and spots before the eyes, loss of vision, hearing may deteriorate. This state can last up to several days.


acute hypertensive encephalopathy. This is a serious condition caused by a significant increase in blood pressure. Occurs due to a violation high blood pressure normal blood supply to the brain. In this condition, confusion, convulsions, transient speech disorders are possible.

Uncomplicated crises - without damage to the "target organs". Such a crisis still poses a threat to the life of the patient. Blood pressure must be reduced within a few hours.

Complicated crises - with the defeat of "target organs". Target organs are those organs that are more or less affected by a given disease. With arterial hypertension, this is the heart, brain, blood vessels, kidneys. Such crises pose a danger to the life of the patient and require an immediate decrease in blood pressure within 1 hour. With a long course of such a crisis, complications from the heart may occur (myocardial infarction, acute insufficiency left ventricle, unstable angina, arrhythmias), blood vessels (dissecting aortic aneurysm, bleeding), brain (stroke, transient ischemic attack, acute hypertensive encephalopathy), kidneys (acute renal failure).

Urgent care:

1) Neurovegetative form of crisis.

Clonidine 0.01% - 0.5 ml in 10 ml of physical. IV solution over 5-7 minutes, or nifedipine 10-30 mg sublingually or propranolol 20-40 mg sublingually

Obzidan 0.1% - 5 ml + droperidol 0.25% - 1-2 ml IV slowly

In the absence of effect: furosemide 40-80 mg IV

2) Edema form

Furosemide 40-80 mg IV

The combination of furosemide 80 mg IV + nifedipine 10-30 mg sublingually or captopril 12.5 mg every 30 minutes for 2 hours

With the threat of complications: 5% solution of pentamin 0.3-1 ml IV slowly in 20 ml of 5% glucose

3) Convulsive form

Furosemide 80 mg IV + 20 mg 25% magnesium sulfate solution IV slowly

Droperidol 0.25% - 1-2 ml IV slowly in 20 ml 5% glucose solution or diazepam 2 ml IV slowly in 5% glucose solution

At the hospital stage:

BP monitoring

Sodium nitroprisside 1-4 mg/kg/min

· Nitroglycerin 10 mg per 100 ml fiz. solution in/in drip

Determination of the type of hemodynamics and selection of therapy

- this is a condition caused by a pronounced increase in blood pressure, accompanied by the appearance or aggravation of clinical symptoms and requiring a controlled decrease in blood pressure to prevent damage to target organs. A rapid and usually sudden increase in blood pressure is provoked by:

  1. neuropsychiatric trauma,
  2. drinking alcohol
  3. sharp fluctuations in atmospheric pressure,
  4. withdrawal of antihypertensive therapy, etc.

Pathogenesis

Two main pathogenetic mechanisms play the main role:

  1. vascular - an increase in total peripheral resistance due to an increase in vasomotor (neurohumoral influences) and basal (with sodium retention) arteriole tone;
  2. cardiac - an increase in cardiac output due to an increase in heart rate, circulating blood volume, and myocardial contractility.

Clinical picture

Clinically, GC is manifested by subjective and objective signs.
Subjective signs include headache, non-systemic dizziness, nausea and vomiting, blurred vision, cardialgia, palpitations and interruptions in the work of the heart, shortness of breath.

To the objective - excitation or lethargy, chills, muscle tremors, increased humidity and flushing of the skin, subfebrile condition, transient symptoms of focal disorders in the central nervous system; tachycardia or bradycardia, extrasystole; accent and splitting of the II tone over the aorta; signs of systolic overload of the left ventricle on the ECG.

Thus, the diagnosis of GC is based on the following main criteria:
sudden onset, individually high rise in blood pressure, the presence of cerebral, cardiac and autonomic symptoms.
The most frequent complaints:
- headache (22%)
- chest pain (27%)
- shortness of breath (22%)
— neurological deficit (21%)
- psychomotor agitation (10%)
- nosebleeds (5%)

Classification. Cupping.

I. Uncomplicated crises are divided into hyperkinetic and hypokinetic:
- Hyperkinetic crises (typically sympathetic-adrenal in pathogenesis) are diagnosed in the presence of tachycardia of more than 90 beats per minute.
- Hypokinetic crises are diagnosed with normo- or bradycardia.

To stop the crisis in both cases, the basic drug is the ACE inhibitor captopril (Capoten) 25 mg under the tongue. When taken sublingually, hypotensive
The action of captopril develops after 10 minutes and lasts about 1 hour.
Second-line drugs for hyperkinetic crisis are betalokZOK (preferably) in the form of an IV infusion of 5-15 mg (conveniently at the pre-hospital stage by the SMP doctor) or sublingual intake of clonidine (clofellin) at a dose of 0.075 mg.

The second-line drug for the relief of a hypokinetic crisis is nifedipine 10 mg sublingually. It has a good predictability of the therapeutic effect: in the vast majority of cases, after 5-30 minutes, a gradual decrease in systolic and diastolic blood pressure begins (by 20-25%) and the patients feel better, which makes it possible to avoid uncomfortable (and sometimes dangerous) parenteral use of antihypertensive drugs for the patient . The duration of the drug is 4-5 hours, which allows you to start at this time the selection of planned antihypertensive therapy. If there is no effect, nifedipine can be repeated after 30 minutes. Clinical observations show that the effectiveness of the drug is higher, the higher the level of the initial blood pressure. Side effects nifedipine is associated with its vasodilatory effect - dizziness, flushing of the skin of the face and neck, tachycardia. Contraindications: tahi-brady syndrome (as a manifestation of weakness syndrome sinus node); severe heart failure; hypersensitivity to nifedipine. It should be borne in mind that in elderly patients the effectiveness of nifedipine increases, so the initial dose of the drug in the treatment of GC should be less than in young patients.
II. Complicated hypertensive crisis is diagnosed in the presence of the following conditions:
- acute cerebrovascular accident
- hypertensive encephalopathy, cerebral edema
- dissecting aortic aneurysm
- acute left ventricular failure
- acute coronary syndrome
- eclampsia
- acute renal failure
Complicated crises require emergency hospitalization. The initial goal of treatment is to reduce blood pressure by no more than 25% (up to 2 hours), over the next 2-6 hours to 160/100 mm Hg. Art.
1. Hypertensive crisis, complicated by transient ischemic attack, acute hypertensive encephalopathy, ischemic stroke: for the relief of this variant of complicated GC, the drugs of choice are beta-blockers. They determine a slow gradual decrease in blood pressure, do not affect intracerebral pressure and thus do not provoke cerebral edema. Betaloc (metoprolol) is used at a dose of 5-10 mg IV drip per 200 ml of isotonic solution. The rate and degree of BP reduction in patients with acute cerebrovascular accident should be considered from the standpoint of changes in cerebral blood flow autoregulation. It should be remembered that the lower limit of autoregulation in patients with hypertension is significantly higher than in healthy individuals, and a decrease in blood pressure even by 25% of the original may be accompanied by a deterioration in blood flow in ischemic areas of the brain. In this aspect, a number of randomized controlled trials are of interest, which have shown that a decrease in
BP in patients with stroke may not improve prognosis.
2. Hypertensive crisis, complicated by hemorrhagic stroke: presents the greatest difficulty in stopping the crisis. This is due to the extreme severity of the course of this crisis, which is due to rapidly progressive cerebral edema with the threat of wedging of the medulla oblongata into the foramen magnum and death of the patient.
In the absence of bradycardia in the treatment of GC complicated by hemorrhagic stroke, metoprolol (betaloc ZOK) at a dose of 5-10 mg intravenously can be used.
3. Hypertensive crisis complicated by acute coronary syndrome(unstable angina, myocardial infarction). The drug of choice for the relief of a crisis are
nitrates (nitroglycerin (5-100 mcg / min IV infusion), perlinganite (5-100 mcg / min, IV infusion) and beta-blockers (metoprolol 5-10 mg IV drip). These drugs
not only contribute to a decrease in blood pressure, but also have a coronary dilating effect, which determines the validity of the use in this situation.
4. Hypertensive crisis, complicated by acute left ventricular failure (cardiac asthma, pulmonary edema). The drugs of choice are fast-acting diuretics (furosemide (Lasix) 20-40 mg IV bolus without dilution) and nitrates (nitroglycerin, perlinganite, sodium nitroprusside, isoket) as an IV infusion. In parallel with the decrease in blood pressure, these drugs determine the decrease in pressure in the pulmonary circulation.

Extremely high blood pressure is defined as 180/120 mm Hg. Art. and higher. This condition can lead to damage to blood vessels. Also, with such high blood pressure, the heart cannot pump blood efficiently. For these reasons, it is important to seek immediate medical attention to reduce the risk of stroke and other cardiovascular complications.


A hypertensive crisis (HK) is a rapid and severe rise in blood pressure that can lead to a stroke or myocardial infarction. Pathological condition most often it is the main complication of hypertension, although in some cases it develops suddenly without any previous signs.

The most common clinical manifestations of hypertension are: cerebral stroke (24.5%), pulmonary edema (22.5%), hypertensive encephalopathy (16.3%) and congestive heart failure (12%). Less commonly, intracranial bleeding, aortic rupture, and eclampsia develop.

A hypertensive crisis is most often determined by an ambulance, although with a long course of the disease, the patient could have experienced sharp rises in blood pressure earlier. In such cases, the clinic could be removed with drugs prescribed by the doctor in advance. In any case, special attention to the patient's condition and a thorough examination of all organs and body systems are required.

Video What is a hypertensive crisis?

Description

A hypertensive crisis encompasses a spectrum of clinical manifestations characterized by uncontrolled high blood pressure leading to progressive or impending organ dysfunction. Under these conditions, blood pressure should be lowered within the maximum allowable time.

Neurological damage to target organs associated with high blood pressure may include hypertensive encephalopathy, cerebral ischemia or stroke, subarachnoid hemorrhage, and/or intracranial hemorrhage.

Cardiovascular organ damage may include myocardial ischemia/infarction, acute left ventricular dysfunction, acute pulmonary edema, and/or aortic rupture. Other organ systems can also be affected by GC, which can lead to acute renal failure, retinopathy, eclampsia, or microangiopathic hemolytic anemia.

The presence of a hypertensive crisis is assessed according to the following criteria:

  • sudden onset;
  • a strong increase in blood pressure;
  • the appearance or strengthening of signs from the target organs.

Additionally, disorders of the autonomic nervous system may appear or intensify. With proper treatment, it is possible to carry out successful prevention of GC, as well as improve the prognostic conclusion for the underlying disease.

There is such a designation of GC as “complicated hypertensive crisis”, which was previously called “malignant hypertension”. Its development is often associated with direct damage to one or more organs, and there must be evidence of such violations. Also in the US and Canada, the term “critical arterial hypertension” is more common.

Thus, only in the post-Soviet space, the following conditional classification for hypertensive crisis is considered:

  • Uncomplicated GC - not complicated by target organ damage
  • Complicated GC - symptoms of damage to target organs are determined.

Some statistics

  • The hypertensive crisis affects 500,000 Americans each year and is therefore the cause of serious morbidity in the US.
  • Approximately 50 million adults suffer from hypertension, of whom the hypertensive crisis accounts for less than 1% per year.
  • About 14% of adults who have been in US hospital emergency departments have systolic blood pressure ≥180 mmHg.
  • As a result of the use of antihypertensive drugs, the rate of hypertension has decreased from 7% to 1% of people with high blood pressure. There was also an increase in survival at 1 year. Until 1950, the rate was 20%, and now it is over 90% with proper treatment.
  • Statistics show that approximately 1% to 2% of people with hypertension experience a hypertensive crisis at some point in their lives.
  • Men are more likely to suffer from hypertensive crises than women.
  • Hospitalizations due to hypertensive crisis tripled from 1983 to 1990, from 23,000 to 73,000/year in the US.
  • The incidence of postoperative hypertensive crisis varies, yet most studies report an incidence of 4% to 35%.
  • Mortality from GC worldwide is 50-75%, while the percentage depends on the development of medical care in a particular country.

Causes

Common causes of hypertensive crisis:

  • irregular intake of drugs for high blood pressure;
  • stroke;
  • heart attack;
  • heart failure;
  • aortic rupture;
  • interaction with drugs;
  • kidney failure;
  • eclampsia.

In pregnant patients, a hypertensive crisis is usually due to hypertension or severe preeclampsia and can lead to maternal stroke, cardiopulmonary decompensation, fetal decompensation caused by reduced uterine perfusion, relapse, and stillbirth. Preeclampsia can also be complicated by pulmonary edema.

Clinic

Signs of a hypertensive crisis include:

  • severe headache;
  • shortness of breath
  • nosebleeds;
  • expressed anxiety.

Other symptoms of a hypertensive crisis may include blurred vision, nausea or vomiting, dizziness or weakness, and problems with thinking, sleeping, and behavior changes.

Statistics on the most common clinical manifestations of hypertensive crisis:

  • Cerebral infarction (24.5%) - fainting, after regaining consciousness, the patient may complain of retrosternal pain.
  • Pulmonary edema (22.5%) - hoarseness, choking, rapid breathing, severe sweating, fear of death.
  • Hypertensive encephalopathy (16.3%) - nausea and vomiting, anxiety, headache, dizziness and convulsions.
  • Congestive heart failure (12%) - weakness, shortness of breath and palpitations, cyanotic skin and mucous membranes, swelling in the legs.

Other clinical manifestations associated with hypertensive crises may include intracranial hemorrhage, aortic rupture and eclampsia, as well as acute myocardial infarction and damage to the retina and kidneys.

Patients may complain of specific symptoms that are associated with end-organ dysfunction. In particular:

  • chest pain often indicates myocardial ischemia or infarction;
  • back pain often means aortic dissection;
  • shortness of breath often
  • associated with pulmonary edema or congestive heart failure.

A neurological syndrome may present with seizures, visual disturbances, and an altered level of consciousness. The presence of such symptoms most often indicates hypertensive encephalopathy.

Clinical signs of malignant HC may include:

  • encephalopathy;
  • confusion of consciousness;
  • disruption of the left ventricle;
  • intravascular coagulation;
  • impaired renal function, with hematuria;
  • weight loss.

The pathological sign of malignant HC is fibrinoid necrosis of arterioles, which is characterized by systemic development, but most often affects the kidneys. These patients develop fatal complications and, if left untreated, more than 90% die within 1–2 years.

Video Hypertension crisis: symptoms and first aid

Diagnostics

The collection of a medical history and physical examination can determine the nature, severity and degree of controllability of a hypertensive crisis. The medical history may focus on the presence of end-organ dysfunction, circumstances associated with hypertension, and any identifiable etiology.

During the diagnosis of GC, the duration and severity of the patient's previous BP elevations (including the degree of BP control), as well as the history of treatment, are assessed. Details of antihypertensive drug therapy, drug use (sympathomimetic agents), and illicit drug use (cocaine) are important elements of the treatment history. In addition, information should be obtained on the presence of prior target organ dysfunction, especially renal and cerebrovascular disease, as well as any other medical problems (eg, thyroid disease, Cushing's disease, systemic lupus erythematosus). For women, the date of their last menstrual cycle is determined.

Physical examination

First of all, the presence of dysfunction in target organs is assessed. Blood pressure should be measured not only in the supine position, but also in a standing position. Measurements are also taken on both forearms. If there is a significant difference in measurements, aortic rupture may be suspected.

Hypertensive crises are diagnosed if systolic blood pressure is determined above 180 mm Hg. Art. or diastolic blood pressure greater than 120 mm Hg. Art.

When examining the retina, new hemorrhages, exudates or papillomas can be determined, then a hypertensive crisis is also confirmed. In the presence of heart failure, there is jugular venous distension, fissures on auscultation, and peripheral edema.

Central nervous system (CNS) findings may include changes in the patient's level of consciousness and visual fields and/or the presence of focal neurological signs.

The severity of a hypertensive crisis is assessed by the following indicators:

  • The level of electrolytes is determined.
  • The level of urea nitrogen in the blood and the level of creatinine are measured to assess kidney failure.
  • A urinalysis is done to check for hematuria or proteinuria and a microscopic urinalysis to look for red blood cells.
  • Is being done general analysis blood smear and peripheral blood smear, which allows to exclude microangiopathic anemia.

If necessary, the concentration of thyroid hormones is determined and other endocrine studies are done.

If pulmonary edema is suspected or the patient has chest pain, an x-ray is taken chest and electrocardiography. Patients with neurological signs should be evaluated with computed tomography or magnetic resonance imaging.

In the malignant course of GC, ophthalmoscopy is mandatory, and in such cases, the patient has a retinal papilledema (as in the photo below). Additionally, optic disc edema is often noted.

Treatment

A hypertensive crisis can be treated through hospitalization followed by oral or intravenous medications.

The main goals of therapy for hypertensive crises:

  1. Safely lower high blood pressure
  2. Protect target organ function
  3. Eliminate symptoms and manifestations
  4. Reduce the likelihood of complications or their severity
  5. Improve clinical outcomes.

In the absence of antihypertensive drug therapy, the average survival of patients is 10.4 months.

Key tactics for the treatment of patients with GC:

  • The drug of choice in the treatment of GC, together with acute aortic dissection, acute myocardial infarction or unstable angina, is esmolol, which is administered intravenously.
    • Blood pressure should be reduced quickly and immediately, usually within 5-10 minutes, especially when determining aortic dissection.
    • Lowering blood pressure is carried out with the help of beta-blockers. If the drugs were ineffective, then vasodilators are used, which are administered intravenously.
    • Target blood pressure is less than 140/90 mmHg. in patients with acute myocardial infarction or unstable angina who do not have hemodynamic disturbances.
  • When combined with GC with pulmonary edema, nitroprusside, nitroglycerin are used, with the exception of beta-blockers.
  • Drugs of choice in the treatment of patients with GC and acute kidney failure is clevidipine, fenoldopam and nicardipine.
  • The drugs of choice in the treatment of patients with hypertensive crisis and eclampsia or preeclampsia are hydralazine, labetalol and nicardipine.

Blood pressure with GC decreases gradually. For the first hour - by about 25%, over the next 6 hours, blood pressure should be reduced to 160/100 mm. rt. Art. In the next 24-48 hours, blood pressure is brought to normal levels.

Hypertensive crisis in pregnant women should be treated immediately to prevent the development of severe complications. Women with hypertension who become pregnant or plan to become pregnant should take methyldopa, nifedipine, and/or labetalol during pregnancy. However, they should not be treated with ACE inhibitors, angiotensin receptor blockers, or direct renin inhibitors.

A gradual decrease in blood pressure is critical to prevent cerebral ischemia as a result of autoregulatory mechanisms.

  • Adults with a hypertensive crisis should be treated in an intensive care unit where blood pressure and target organ damage are continuously monitored. Parenteral administration of appropriate drugs is also carried out.
  • In adults with severe complications of GC (eg, aortic dissection, severe preeclampsia or eclampsia, exacerbation of pheochromocytoma), blood pressure falls below normal - less than 140 mm Hg. Art. during the first hour and less than 120 mm Hg. Art. with aortic dissection.
  • In adults without serious illness, but with GC, blood pressure decreases by up to 25% within the first hour. If the patient is clinically stable, blood pressure drops to 160/100 -110 mm Hg. over the next 2-6 hours, and then gently to normal levels over the next 24-48 hours.

Forecast

The long-term prognosis for patients with frequent hypertensive crises is defined as unfavorable. Basically, short-term death occurs from severe damage to the nervous system. It is also common for complications such as cardiovascular diseases leading to death over the next 12 months.

Prevention

Prevention of a hypertensive crisis is possible by educating patients with hypertension. Information about this today is widespread and important. Some factors can lead to an uncontrolled rise in blood pressure, so you should, if possible, influence them:

  • Hyperlipidemia - lipid profile should be kept within the normal range.
  • Uncontrolled diabetes - it is important to follow medical advice to prevent the progression of the disease.
  • Missing doses of antihypertensive drugs - you need to adhere to the dosages and frequency of taking medications that help control blood pressure.

Old age is another factor that contributes to the development of HC, but it is almost impossible to influence it..

Important in the prevention of GC is the conduct of extensive education of patients with hypertension on the content within the allowable weight. For this, a special diet is most often used. Also, the doctor, if necessary, prescribes exercises to prevent diabetes, high blood pressure, cardiovascular disease and hyperlipidemia.

All these medical conditions are closely interrelated and need to be balanced. Special attention should be paid to compliance with medical procedures for the prevention of stroke and cardiovascular diseases.

Video Live Healthy! Hypertensive crisis